The effect of interventions to reduce potentially inappropriate antibiotic prescribing in long-term care facilities: a systematic review of randomised controlled trials.

BACKGROUND The prevalence of antibiotic use in long-term care facilities (LTCF) is high and in many cases it may not be in accordance with local guidelines. It is important to review interventions that aim to improve the quality of antibiotic prescribing in this setting. OBJECTIVE The objective of this systematic review was to collect and interpret the results of studies of interventions to improve the quality of, or appropriateness of antibiotic prescribing in LTCF in order to determine the key components for a successful intervention. DATA SOURCES A search of The Cochrane Library, PubMed, EMBASE, ISI Web of Knowledge, International Pharmaceutical Abstracts, the Database of Abstracts of Review of Effects (DARE), the Health Technology Assessments (HTA) at the Centres for Reviews and Dissemination (CRD) and Google Scholar was conducted from their inception to August 2012. A manual search of the grey literature and relevant journals was also conducted. STUDY SELECTION Studies were selected that were randomised controlled trials of an intervention to improve the quality of antibiotic prescribing, or increase adherence to a prescribing guideline or reduce the amount of antibiotic prescribing. All studies were conducted in the long-term care setting. The search strategy found four randomised controlled trials that met the inclusion criteria, from an initial 1,904 titles. STUDY APPRAISAL AND SYNTHESIS METHODS The risk of bias assessment of the included studies was conducted using the Cochrane Risk of Bias Table. Due to the heterogeneity of the interventions, study designs and outcome measures, a meta-analysis was not conducted. RESULTS Four studies met the inclusion criteria for this review. Three studies directed educational material and sessions at physicians and nurses, with one of the three studies providing prescribing feedback as well. The fourth study provided educational material and prescribing feedback for physicians only. Due to the mixed and modest effects of the interventions and the variety of interventions implemented, it is difficult to attribute the success of any intervention to just one component alone. It seems that a multifaceted intervention involving small group educational sessions and the provision of educational materials is generally acceptable to nurses and physicians in LTCF. The involvement of local consensus procedures when developing guidelines and interventions may improve the success of the intervention. LIMITATIONS A limitation of this systematic review is the small number of studies that met the inclusion criteria. CONCLUSION Interventions in the long-term care setting involving local consensus procedures, educational strategies, and locally developed guidelines may improve the quality of antibiotic prescribing, but the quality of the evidence is low. Due to the poor quality of evidence and mixed results, no definitive conclusion can be reached about the effect of the interventions. Future research in this area needs to include process evaluation research in order to define the characteristics contributing to the success or failure of any intervention. The contribution of a multidisciplinary antibiotic management team, which could include a pharmacist, a nurse and specialists in microbiology and infectious diseases and geriatrics, needs further investigation in order to improve antibiotic prescribing practices in LTCF.